Introduction by Croakey: The recent declaration by United States President Joe Biden that “the pandemic is over” caught many by surprise, and has been criticised for “seeming to play politics with public health”.
As global health expert Professor Gavin Yamey wrote in Time magazine, the COVID pandemic is far from over but the President’s apparently unilateral declaration highlights that the ending of any pandemic is not determined solely by science or public health data, but involves social and political considerations, and that it does not come in a moment but as a process – “one that can be messy and highly contested”.
In Australia, where public debate about COVID remains messy and contested, Federal Health Minister Mark Butler made clear this week that COVID is not over, signalling the need for ongoing investment and programs well into next year. Announcing $1.4 billion to extend COVID-19 response measures, he also highlighted the current and future toll of Long COVID.
Butler said $42 million would be invested in community campaigns for the rest of this year and the first half of 2023, with targeted campaigns for First Nations communities. He was also keen “to explore the way in which we can target communications campaigns better to culturally and linguistically diverse communities to make sure that those communities are given the fullest possible information about their choices around vaccines, around treatments, and around good COVID-safe behaviour in their communities”.
Governments’ commitment to prevention, however, is far from clear; the Australian Medical Association today said it was disappointed by state governments’ decision to drop mask mandates on public transport without notice, clear guidance or public health advice.
AMA President Professor Steve Robson said governments were continuing to make serious decisions with no consultation and no discussion about how to prepare for the consequences. NSW and South Australia will now join the ACT, Western Australia, Northern Territory and Tasmania in not requiring public transport passengers to mask-up.
“This is a major decision which will have consequences and it should have been done with national consensus and clear health guidance,” he said in a statement. “Many of our most vulnerable people in the community are the ones that use public transport the most. Masks are the last of the sensible protections and we urge people not to abandon using them.”
Meanwhile, in the latest edition of The Health Wrap, Adjunct Associate Professor Lesley Russell reviews wider pandemic developments, new evidence on the benefits of physical activity for healthy ageing and some incredible corporate leadership. (Editor’s note: This column was filed before Minister Butler’s announcement on 19 September).
Lesley Russell writes:
New reports and data highlight that Australia is not on top of the COVID-19 pandemic. As my Croakey colleague Dr Amy Coopes wrote recently, National Cabinet has acted to reduce COVID-19 protections, even as new data reveal the pandemic death toll.
The latest bulletin from the Australian Health Protection Principal Committee (AHPPC) regarding a reduced isolation period for those with COVID-19 is headed as noting “the need for a proportionate approach to isolation for those with COVID‑19 infections at this stage of the pandemic”.
But a “proportionate approach” seems to be “let it rip” and the inevitable effect is that people are dying. Last week there were some 250 deaths from COVID-19 – and a move to reporting the statistics weekly does not make the numbers any better.
Sadly, despite expectations, the Albanese Government does not seem to be doing any better than the former Coalition Government in terms of tackling infections in residential aged care, getting boosters shots into arms, and persuading Australians that ongoing individual and community safeguards against infection are still needed.
New reports also highlight the gaps in data collection. To be blunt, Australia does a lousy job of collecting useful COVID-19 data (ie information that could help with better targeting vaccination and information programs) about culture, language, race and ethnicity.
There is plenty of scope here for the recently established parliamentary investigation, despite its specific focus on long-COVID and repeat COVID-19 infections. Or maybe we need a Royal Commission and a full-scale inquiry?
Eminent researchers from the Burnet Institute make the case in an article published in The Conversation that what’s needed is a shared vision and a strategic COVID plan that acknowledges it is not “just like the flu”.
Newly elected Teal parliamentarian Dr Monique Ryan has called on the Federal Government to rethink pandemic management and has called for a national summit.
Australian Institute of Health and Welfare report
A new report from the Australian Institute of Health and Welfare – The Impact of a new disease: COVID-19 from 2020, 2021 and into 2022 – and additional, more recent, Australian and international data boost my criticisms.
1. By 30 April 2022, the cumulative incidence of COVID-19 was 231,000 cases per million people and the number of reported deaths was 5335; 3107 of these were in 2022. The number of reported deaths here seems very low – the WHO data says 7,225 deaths by 25 April, 2022.
Updates highlight the dreadful impact of “opening up”:
- WHO reports that on 13 September Australia had a cumulative total of 36,656 confirmed cases per 100,000 people, ranking it among the very worst internationally. The American cumulative total was 28,398 cases per 100,000 people – although under-reporting is likely worse in the United States.
- The Department of Health (DoH) website is reporting 14,421 deaths by 9 September (the WHO reports a similar number) – an appalling increase since April. However, the death rate in Australia is much better than that for most other developed countries. For example, WHO reports the Australian death rate at 56.5 cases per 100,000 compared to the United States at 314.1 cases per 100,000. I’m not sure we should regard this as a consolation, but it does highlight how well our public healthcare system has performed under very difficult circumstances.
2. The AIHW is curiously low-key on reporting the residential aged care data, and gives this only for 2020, when 75 percent of all aged care deaths were residents of aged care facilities.
More recent information highlights that the rates of COVID-19 infection and death in aged care are still high:
- The most recent weekly report on the DoH website for the week of 2 September to 9 September shows that there were 11456 new cases of COVID-19 in residents and staff and 53 resident deaths.
- The rates of both are (finally) trending down, after peaks in August, April- May and January. So far in 2022 (to 9 September) there have been 3116 deaths from COVID-19 in aged care facilities – curiously reported by DoH as 6.5 percent of total deaths (47,937), as if they can’t they bring themselves to face reality! The reality is very tough: the deaths so far in 2022 are more than triple those in both 2020 (when we were so appalled at 686 deaths) and 2021 (231 deaths).
- In 2020, more than 33 percent of COVID-19 cases in residents resulted in deaths, but this has dropped to 3.5 percent in 2022. 81.6 percent of eligible residents have now had their fourth vaccine dose.
Let’s hope the recently-established parliamentary inquiry will be looking at the adequacy of the Albanese Government’s winter plan for aged care homes.
3. The rate of severe disease during the Omicron wave (figures are to 3 July 2022) for Indigenous people was 1.4 times as high as for non-Indigenous Australians.
- Additional reporting on the impact of the pandemic on Aboriginal and Torres Strait Islander people is hard to find. There is some information in the regularly-produced Communicable Disease Intelligence reports.
- In the entire Omicron wave to 31 July 2022 (the most recent report), there were 247,300 cases of COVID-19 notified in Aboriginal and Torres Strait Islander people, representing 3 percent of all reported cases. Almost half (104,060) of these cases were in New South Wales and only 27, 907 of the total cases were in remote communities.
4. Nationally, 212 COVID-19 deaths have been reported in Aboriginal and Torres Strait Islander people from the start of the pandemic to 31 July 2022.
People from lower socio-economic groups and those born overseas, especially in North Africa and the Middle East, had higher COVID-19 mortality rates than other Australian residents.
The Australian Bureau of Statistics (ABS) has information of COVID-19 deaths by country of birth.
- The most recent ABS data (to 30 June 2022) show that those who died of COVID-19 with a country of birth of overseas, had an age-standardised death rate two times higher than that of people who were born in Australia (15.6 deaths per 100,000 people versus 7.6 deaths).
- Those with a country of birth in the Middle East had the highest age-standardised death rate at 46.9 deaths per 100,000 people.
Report from New South Wales Ombudsman
The second report on the COVID-19 pandemic from the NSW Ombudsman was recently released. This looks at the second year (2021-2022) of the pandemic through the lens of complaints to the Ombudsman about actions taken by NSW Government agencies. The first report is available here.
It makes very interesting reading. My summary of what I see as the key points follows.
- Complaints related to COVID-19 were 125 percent higher in 2021-22 than in 2020-2021 (1,046 vs 463). The biggest increase in complaints was in the custodial system. There were 436 complaints about mandatory hotel quarantine which was phased out in late 2021.
- The report makes the case that “a visible, accessible and properly functioning complaint-handling system is particularly important during a pandemic” when parliamentary governance and oversight may be sidelined in favour of emergency executive powers used to “impose significant and unusual incursions on individual rights.”
- The primary tool the NSW State Government used to implement its pandemic response was not the standard model of law-making (parliamentary acts and regulations) but public health orders made usually by the Minister for Health under the state’s Public Health Act.
- Directions made under such an order are reviewable, but the decision to make a public health order is not. This is the norm in all Australian jurisdictions (helps explain why Morrison wanted to be federal Minister for Health).
- In NSW, the sheer number of state public health orders, and the frequency with which they were modified, made it difficult for individuals and businesses to know what was required of them. The order were published only in English and were often lengthy and legally complex. There was confusion between rules (hard laws) and guidance (soft laws).
The Ombudsman made the following points about these rules:
- There was not a lot of common-sense in the rules (eg the rationale behind the limit on the number of people who could visit a house was not obvious).
- Some of the rules were not enforceable (eg the requirement to report a positive rapid antigen test).
- There was a disproportionate number of enforcement actions in those Local Government Areas that are home to marginalised communities, including Aboriginal and Torres Strait Islander people and CALD populations.
- Penalties were not always proportional to the rule-breaking offence and even children were fined.
In the previous report, the Ombudsman had made the case that the current oversight and complaint-handling system is not well-suited to the issues around the COVID-19 pandemic and suggestions were made for improvements. The NSW Government has not yet taken steps to implement these.
In particular, the Ombudsman points out that NSW is the only state yet to make any public progress on the implementation of the Optional Protocol to the United Nations Convention Against Torture (OPCAT). This is particularly important for ensuring the rights of people in prison and other forms of detention during a pandemic.
As a recent Croakey article highlights, Australia as a whole has been slow the implement the required National Preventative Mechanisms, which should be in place by January 2023.
Global lessons from the COVID pandemic
The Lancet Commission has just released a report on lessons for the future from the pandemic. The report details the failure of wealthy countries (like Australia) and pharmaceutical companies to ensure the tools needed to end the pandemic were accessible to everyone globally.
The report makes the following findings:
- The WHO acted too cautiously and too slowly on several important matters, including warning about the human transmissibility of the virus, declaring a Public Health Emergency of International Concern, and recognising the airborne transmission of the virus.
- As the outbreak became known globally in early 2020, most governments around the world were too slow to acknowledge its importance and act with urgency in response.
- Coordination among governments was inadequate on policies to contain the pandemic, including travel protocols to slow the global transmission of the virus, data standards and reporting systems, and advice to the public.
- Epidemic control was seriously hindered by substantial public opposition to routine public health and social measures. This opposition reflects a lack of social trust, low confidence in government advice, inconsistency of government advice, low health literacy, lack of sufficient behavioural-change interventions, and extensive misinformation and disinformation campaigns on social media.
- Public policies did not properly address the profoundly unequal effects of the pandemic.
- Among high-income countries, those with strong and resilient national health systems have generally fared better at addressing COVID-19 and maintaining non-pandemic-related health services.
- Rapid development of multiple vaccines has been a triumph of the research and development system. However, there has been inequitable access to vaccines.
- Economic recovery depends on sustaining high rates of vaccination coverage and low rates of new COVID-19 infections, and on fiscal and monetary policies to mitigate the socioeconomic effects of the pandemic.
- The sustainable development process has been set back by several years, with a deep underfinancing of investments needed to achieve the Sustainable Development Goals (SDGs) and the aims of the Paris Climate Agreement.
- There is a list of recommendations to address these issues. While some are quite obvious, I suspect others will prove to be controversial.
- Globally coordinated efforts to bring an end to the COVID-19 pandemic on a rapid and equitable basis.
- WHO, governments, and the scientific community should intensify the search for the origins of SARS-CoV-2, investigating both a possible zoonotic origin and a possible research-associated origin.
- WHO should expand the WHO Science Council to apply urgent scientific evidence for global health priorities, including future emerging infectious diseases.
- Governments, through the World Health Assembly (WHA), should establish stronger means of cooperation and coordination in the response to emerging infectious diseases.
- WHO should be strengthened with a WHO Global Health Board and a substantial increase of its core budget. The central role of WHO should not be undermined by other bodies.
- WHO should be given new oversight authority regarding the biosafety, biosecurity, and bio-risk management of national and international research programs that are engaged in the collection, testing, and genetic manipulation of potentially dangerous pathogens.
- The WHA, in conjunction with the G20 countries, should adopt a 10-year global strategy to bolster research and development capacity and commodity production capacity—including for vaccines—for every WHO region.
- Countries should strengthen national health systems on the foundations of public health and universal health coverage, grounded in human rights and gender equality.
- Countries should determine and expand national pandemic preparedness plans to prevent and respond to newly emerging infectious diseases.
- A new Global Health Fund should be created that is closely aligned with WHO. This Fund should combine and expand the operations of several existing (un-named) health funds.
Meanwhile, a recent investigative report from US-based Politico looks at the “Big Four” non-government organisations (NGOs) (Bill & Melinda Gates Foundation, Wellcome Trust, Coalition for Epidemic Preparedness Innovations, or CEPI, and GAVI, the Vaccine Alliance that controls COVAX) that control billions of dollars in funds and have a pivotal influence over global health- and pandemic- related policies.
These NGOs, all linked to WHO, are working closely together and to date have spent almost US$10 billion on their international responses to the pandemic. There has been some excellent work done. But as the Politico investigation shows there has been little government oversight and they have all fallen well short of their own goals.
You can read more here and here.
A Twitter thread from respected science journalist Laurie Garrett provides a succinct summary of these two reports.
The WHO has welcomed “the overarching recommendations” of The Lancet COVID-19 Commission’s report that align with “our commitment to stronger global, regional and national pandemic preparedness, prevention, readiness and response”.
However, the WHO says there are several key omissions and misinterpretations in the report, about the public health emergency of international concern (PHEIC) and the speed and scope of WHO’s actions. Read more here.
US updates its Global Response and Recovery Framework
On 15 September the Biden Administration released an update to the COVID-19 Global Response and Recovery Framework first issued in July 2021.
It acknowledges that, while progress has been made (mostly via vaccination programs), inequities persist, and gaps in the global health security architecture leave the world vulnerable to future COVID-19 variants and other pandemic threats.
Of course the biggest progress is that under President Biden the United States now has an (updated) outline of how the world’s richest nation will help lead the international fight to address the pandemic: there was no such plan under former President Trump’s “America First” foreign policy.
Trump threatened to withdraw the United States from the WHO, refused to be involved in COVAX and it has been revealed that his Administration’s contracts with US vaccine manufacturers prohibited them from sharing surplus COVID-19 vaccines with the rest of the world.
Biden has committed to provide some 1.1 billion vaccine doses for international aid by 2023; to date 630 million doses have been donated.
New variants and bold calls
At a press briefing in Geneva this past week, WHO Director-General Tedros Adhanom Ghebreyesus was very optimistic that the world was at a turning point in the pandemic. His optimism stems from the fact that currently the number of weekly coronavirus deaths worldwide is the lowest since March 2020.
However, he did warn governments not to drop the ball but to strengthen their COVID policies and “to run harder”. He said, “If we don’t take this opportunity now, we run the risk of more variants, more deaths, more disruption and more uncertainty.”
Given that the Northern hemisphere is about to enter winter, and that only 68 percent of the world’s population has received at least once vaccine dose, I think his prediction that we are nearing the end of the pandemic is a pretty bold call. I suspect many infectious disease experts do too.
And remember WHO officials said in January that the omicron variant offered “plausible hope for stabilisation and normalisation” in Europe but the pandemic was “entering a new phase.” Well it was – but not in a positive sense!
On the same day Dr Tedros was making positive prognostications, the WHO Regional Director for Europe, Dr Hans Henri Kluge said this: “The pandemic itself is far from over. Too many people are still dying unnecessarily – more than 3000 last week in our Region. And we’re expecting a surge in the autumn and winter, with many people still unvaccinated.”
An article published in Nature Reviews Microbiology earlier this year and reviewed on the European Commission website outlines how scientists are worried that the rapid antigenic evolution of SARS-CoV-2 is likely to produce new, potentially more virulent variants.
They argue that the unpredictable antigenic evolution of SARS-CoV-2 will lead to new variants that may escape the current immunity and so could potentially be more severe. They warn that there is no guarantee that future variants will be milder, as was the case with Omicron.
Meanwhile, BA.4.6, a subvariant of the omicron COVID variant which has been quickly gaining traction in the US, is now confirmed to be spreading in the UK, according to Dr Manal Mohammed, a Senior Lecturer of Medical Microbiology at University of Westminster
Writing in The Conversation, she says the latest briefing document on COVID variants from the UK Health Security Agency (UKHSA) noted that during the week beginning August 14, BA.4.6 accounted for 3.3% of samples in the UK. It has since grown to make up around 9% of sequenced cases.
Similarly, according to the Centers for Disease Control and Prevention, BA.4.6 now accounts for more than 9% of recent cases across the US. The variant has also been identified in several other countries around the world.
“Close monitoring of new variants including BA.4.6 is pressing, as they could lead to the next wave of COVID pandemic. For the public, it will pay to stay cautious, and comply with any public health measures in place to prevent the spread of what remains a very contagious virus,” writes Mohammed.
Exercise and the elderly
A combination of my addiction to hiking, my new-found status as a gym rat, and an ever-growing number of birthdays means that I am always interested in the topic of exercise and the elderly.
There are a number of recent publications around this topic.
1. Delaying and reversing frailty: a systematic review of primary care interventions
This BMJ paper looks at the most effective and practical interventions for frailty in the elderly. It was generated because tin England frailty identification is an NHS contractual requirement. It found that a combination of muscle strength training and protein supplementation was the most effective intervention to delay or reverse frailty and the easiest to implement in primary care.
2. The importance of muscle strength
A paper published earlier this year in the Journal of Cardiopulmonary Rehabilitation and Prevention looks at the importance of adding exercises to increase muscular strength to cardiovascular exercises, especially for older patients.
3. How cycling has a positive effect on the ageing process
A recent article in The Sydney Morning Herald highlights the positive benefits of cycling on the ageing process, which may explain why the participation rate among adults aged over 50 in cycling is rising significantly ( I might add here – despite concerns about the safety of cycling in many areas that lack dedicated bike lanes!).
Research indicates that exercise increases blood flow to the brain which improves cognitive function, enhances brain cell regeneration, and slows the ageing process. Cycling in older age can improve balance and fear of falling.
Cycling outdoors, and engaging with nature, also improves psychological well-being.
4. Dementia risk and daily step count
If, like me, you are a bit obsessed with your daily step count, then you have probably followed the ongoing debates around how many steps deliver health benefits.
A large-scale longitudinal study conducted in the United Kingdom and reported in JAMA Neurology found that a daily total of 3,800 to 9,800 steps was tied to lower dementia risk. Step intensity mattered. The optimal cadence dose for the highest 30 minutes of the day was 112 steps per minute.
Physical activity, aged care and physiotherapy
It’s an easy segue from the last set of topics to this one. Perhaps I could argue that more attention to exercise earlier in life would protect against physical frailty and dementia in later life?
A very interesting study published in PLOS One and summarised in The Conversation looks at how aged care residents spend their time.
It’s encouraging to see that residents were largely active, both in terms of communicating with other people and in doing activities.
It highlights the importance of social interactions but says little about how physically active they are, or could be with just a few enablers.
As an aside here – have you been watching Old People’s Home for Teenagers on ABC? It’s every insightful about how two very vulnerable groups – physically frail old people and anxious young people – can come together and form string bonds that benefit everyone. Why aren’t there more programs like this?
A 2018 paper from researchers at the University of Sydney found limited evidence exists concerning knowledge and understanding of how to optimally support aged care residents’ physical activity, mobility and functional independence.
Their research showed that although maintaining independence was found to be the utmost priority for nearly all participants in this study, many did not make the connection between physical activity and independence, and regarded ‘exercise’ as an inappropriate activity for them. However, walking and gardening were popular activities that could be better utilised.
Helping aged care residents to improve or regain mobility not merely improves quality of life, but reduces the risks of falls, and potentially reduces costs for providers by enabling residents to perform basic self-care tasks instead of needing staff assistance. Physiotherapy can be an important aid here.
A recent article in The Mandarin highlights problems with the way physiotherapists are funded to provide care in residential aged care facilities (RACFs) – a legacy of the Morrison/Colbeck era that we must hope Minister for Health and Aged Care Mark Butler and Minister for Aged Care Annika Wells look to address soon.
Until recently, aged care providers were funded for four sessions of 20 minutes of physiotherapy a week – but this was limited to pain management. The Aged